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In-network benefits

When you go to a doctor or hospital that accepts this plan, that's called getting your care in-network.

Because this plan is a PPO, it'll share the cost for some services if you go to a doctor or hospital that doesn't take this plan. That's called getting your care out-of-network. Those benefits are listed on a separate table below.

Why are there two deductibles?

When you're in the hospital or another facility as an inpatient, the bills you pay will count toward your inpatient deductible. Most other services — including doctor office visits, prescription drugs and emergency care — will count toward your outpatient deductible.

You'll never pay the full amount of both deductibles

Your out-of-pocket maximum will cap your costs at:

  • $6,350 for an individual
  • $12,700 for a family

Your in-network deductibles

Be sure to compare your before and after deductible costs. It makes a big difference in what you have to pay. This plan has two in-network deductibles:

Outpatient deductible:

  • $6,350 for an individual
  • $12,700 for a family (two or more members)

Inpatient deductible:

  • $4,400 for an individual
  • $8,800 for a family (two or more members)
What we call it What it is When you pay What you pay
Preventive services
Exams, prescriptions, tests and shots you get when you’re well to prevent illness and injury

Anytime $0
Pediatric services
Children can get pediatric benefits until the end of the calendar year in which they turn 19.
Check-ups children get when they’re well
Anytime $0

Vision care for children: Eye exam and glasses or contacts
Once a year $0
Ambulatory services Office visit to your primary care doctor
Before deductible All costs
After deductible $0
Office visit to a specialist
Before deductible
All costs
After deductible $0
Laboratory and diagnostic services

Includes:

  • Lab tests
  • Radiology services like X-rays, EKGs and ultrasounds
  • Allergy testing and shots
  • Imaging services like MRIs
Before deductible
All costs
After outpatient deductible $0
After inpatient deductible 40%
What we call it What it is When you pay What you pay
Maternity and newborn care

Doctor office visits while pregnant

  • Tests and ultrasounds you get during the visit are billed under laboratory services
Anytime $0
Care you get when you deliver your baby in the hospital
Before deductible All costs
After outpatient deductible $0
After inpatient deductible 40% + $500
Emergency services Emergency room Before deductible All costs
After deductible $0
Transportation by ambulance Before deductible All costs
After deductible $0
Urgent care
Before deductible All costs
After deductible $0
Hospitalization and other services Care you get when you’re in the hospital for at least one night Before deductible All costs
After deductible 40% + $500
Hospice care
Before deductible All costs
After deductible $0
Most other services, like inpatient and outpatient surgery, chemotherapy, home health care and sleep studies Before deductible All costs
After outpatient deductible $0
After inpatient deductible 40%
What we call it
What it is
When you pay
What you pay
Rehabilitative and habilitative services and devices
Services that help you recover from an injury or illness, like:
  • Physical and occupational therapy
  • Spinal manipulation from a chiropractor
  • Speech therapy
  • Diabetes supplies
Before deductible All costs
After deductible $0
Durable medical equipment, like a wheelchair, walker or oxygen tank Before deductible All costs
After outpatient deductible $0
After inpatient deductible 50%
Mental health/substance abuse Care you get at a mental health or substance abuse facility as an inpatient Before deductible All costs
After deductible 40% + $500
Office visit to an outpatient mental health or substance abuse facility Before deductible All costs
After deductible $0

Out-of-network benefits

What you'll pay if you go to a doctor or hospital that doesn't accept this plan.

Why are there two deductibles?

When you're in the hospital or another facility as an inpatient, the bills you pay will count toward your inpatient deductible. Most other services -- including doctor office visits, prescription drugs and emergency care -- will count toward your outpatient deductible.

You'll never pay the full amount of both deductibles

Your out-of-pocket maximum will cap your costs at:

  • $12,700 for an individual
  • $25,400 for a family

Your out-of-network deductibles

Be sure to compare your before and after deductible costs. It makes a big difference in what you have to pay. This plan has two out-of-network deductibles:

Outpatient deductible:

  • $12,700 for an individual
  • $25,400 for a family (two or more members)

Inpatient deductible:

  • $8,800 for an individual
  • $17,600 for a family (two or more members)
What we call it What it is When you pay What you pay
Preventive services
Exams, prescriptions, tests and shots you get when you’re well to prevent illness and injury

Anytime All costs
Pediatric services
Check-ups children age 18 and younger get when they’re well.
Anytime All costs

Vision care for children age 18 and younger: Eye exam and glasses or contacts.
Once a year $0
Ambulatory services Office visit to your primary care physician
Anytime All costs
Office visit to a specialist with a referral
Anytime
All costs
Laboratory and diagnostic services Includes:
  • Lab tests
  • Radiology services like X-rays, EKGs and ultrasounds
Before deductible All costs
After outpatient deductible $0
After inpatient deductible 60%
Allergy testing and shots Anytime All costs
  Imaging services like MRIs Before deductible All costs
After outpatient deductible $0
After inpatient deductible 60%
What we call it What it is When you pay What you pay
Maternity and newborn care

Doctor office visits while pregnant

  • Tests you get during the visit are billed under laboratory services
Before deductible
All costs
After outpatient deductible $0
After inpatient deductible 60%
Care you get when you deliver your baby in the hospital
Before deductible All costs
After outpatient deductible $0
After inpatient deductible 60% + $500
Emergency services Emergency room Before in-network deductible All costs
After in-network deductible $0
Transportation by ambulance Before in-network deductible All costs
After in-network deductible $0
Urgent care
Before deductible All costs
After deductible $0
Hospitalization and other services Care you get when you’re in the hospital for at least one night Before deductible All costs
After deductible 60% + $500
Hospice care
Anytime All costs
Most other services, like inpatient and outpatient surgery, chemotherapy and sleep studies Before deductible All costs
After outpatient deductible $0
After inpatient deductible 60%
What we call it
What it is
When you pay
What you pay
Rehabilitative and habilitative services and devices
Services that help you recover from an injury or illness, like:
  • Physical and occupational therapy
  • Spinal manipulation from a chiropractor
  • Speech therapy
  • Diabetes supplies
Before deductible All costs
After deductible $0
Durable medical equipment, like a wheelchair, walker or oxygen tank Before deductible All costs
After outpatient deductible $0
After inpatient deductible 70%
Mental health/substance abuse Mental health care you get as an inpatient in a hospital or residential facility Before deductible All costs
After deductible 60% + $500
Mental health care you get as an outpatient Before deductible All costs
After deductible $0
Treatment you get for substance abuse as an inpatient in a hospital or residential facility Anytime All costs
Treatment you get for substance abuse as an outpatient Anytime All costs